The use of Pre-operative Virtual Reality to Reduce Anxiety in Women Undergoing Gynecological Surgeries

A Prospective Cohort Study

Jason Ju In Chan; Cheng Teng Yeam; Hwei Min Kee; Chin Wen Tan; Rehena Sultana; Alex Tiong Heng Sia; Ban Leong Sng


BMC Anesthesiol. 2020;20(261) 

In This Article


By examining patients using VR intervention before undergoing minor gynecological procedures, we found that the use of a 10-min VR intervention resulted in a statistically significant reduction of pre-operative anxiety and depressive symptoms as measured using the HADS. While the pain scores collected pre- and post-VR intervention did not reveal any significantly changes, EQ-5D-3L measures further revealed that pre-operative self-reported perception of pain and discomfort and perceived health states were improved after VR intervention.

This study revealed that there is significant preoperative anxiety amongst the gynecological patients recruited, and is in congruence with other studies using HADS to measure changes in pre-operative anxiety for VR interventions in oncology patients[29,30] and patients in intensive care.[31] Surgery is a daunting experience that comes with emotional vulnerabilities. These emotions are often intensified moments before surgery, causing overwhelming anxiety and even depressive moods.[32] Increased preoperative anxiety is associated with postponement or even cancellation of planned surgeries, increase in anesthetic requirements, prolonged hospital stay and poorer overall patient satisfaction.[33,34]

Patient-centric outcomes were investigated as part of our secondary outcomes in this study using the EQ-5D-3L. This provided other insights into patients' health conditions, baseline functional status and quality of life. In this study, EQ-5D-3L assessment showed statistically significant improvement on self-reported pain/discomfort and anxiety/depression dimensions before gynecological surgery when VR was used. In addition, self-reported perception of 'usual activities' dimension also showed improvement post-VR. Furthermore, patients had overall positive self-reported satisfaction for the VR experience prior to their scheduled gynecological procedure.

In previous studies, patients who received VR treatment reported a reduction in pain and anxiety,[16] faster wound healing,[35] decreased chronic pain intensity[15] and other neuro-rehabilitation improvements.[36] These results largely corroborated with our findings, which showed reduction in anxiety. While the exact neurobiological mechanistic theory behind VR's action remain unclear, it is generally suggested that VR acts as a distraction by rendering several possible mechanisms by: i) engaging different senses simultaneously and inducing a sense of presence in the virtual environment, thus diverting one's attention from painful stimuli and other negative emotions such as stress and anxiety;[37] ii) employing attentional resources in immersive and interactive virtual environments to modulate ascending nociceptive stimuli and thus reduce pain experience;[38] iii) isolating the user both visually and acoustically from the actual environment to escape from the painful world cognitively.[39] VR could serve as a non-pharmacological intervention in clinical settings to modulate emotional affective, emotion-based cognitive and attentional processes.[40] Interestingly, although the mean pain scores pre- and post-VR intervention were not statistically significant, there was an improvement of self-reported perception in the dimension of 'pain/discomfort' in the EQ-5D-3L. The pain score changes could be attributed to pre-surgical administration of vaginal or oral prostaglandins for cervical softening.

Study Limitations. There were several limitations in our study. Firstly, the instruments used for assessment of anxiety were dependent on self-reported psychometric questionnaires. Although these psychometric tools have been validated in previous studies with similar target populations, there might be more suitable and sensitive measures of anxiety (e.g. STAI) and other psychometric measures (e.g. pain catastrophizing scale (PCS), perceived stress scale (PSS)) to reflect the effects of VR intervention on patients' psychological profiles.[41,42] Secondly, the patient population selected had to have the ability to read and understand English, which might limit the sociodemographic profiles of patients.

Thirdly, multiple factors unrelated to surgery could influence pre-operative anxiety. For example, we did not investigate interactions between study team investigator and the patient. Non-study team members and the surrounding environment may also affect the patient's mood and anxiety. The effects of different scenarios on anxiety scores were also not studied due to an unequal distribution of scenarios that were chosen by patients. Finally, there was a lack of a control group to compare anxiety scores without VR intervention, making it difficult to assess the true effect of VR on pre-operative anxiety. Future randomized controlled trials are needed to validate our findings in this study.